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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test 0 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10182243 3/27/2019 Business Name (Same as Facility Name or DBA-Doing Business As) MAIN STREET ARCO - J S K S Business Site Address City ZIP Code 1100 S . MAIN STREET MANTECA 95337 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # Zane Nimmo (209 ) 744- 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 3/31 / 19 8883064 - UT 6/ 1 /2019 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 /29/2020 OPW # 104-632 Ex . 3/ 14/2020 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : Rx Manufacturer Guidelines (Specify) : O P W PHASE I LAKE TESTING R Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (Bytanknumber, storedproduct, etc.) 1 - 91 OCT 2 - 87 SOUTH 3 - 87 NORTH 4 - 89 OCT Spill Container Manufacturer: O P W O P W O P W O P W Method of Cathodic Protection : Z Non-Metallic ❑x Non-Metallic 0 Non-Metallic Z Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specifyin V.) 1 Z Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) Inside Diameter of Spill Container: (Inches) 11 11 11 11 Depth of Spill Container: (Inches) 14 14 14 14 Does the spill container have a 5 gallon capacity? R Yes ❑ No R Yes R No ❑x Yes ❑ No ❑x Yes ❑ No Method to Keep Spill Container Empty: Rx Drain Valve ❑x Drain Valve x Drain Valve 0 Drain Valve R Onsite Pump ❑ Onsite Pump R Onsite Pump R Onsite Pump Z Other (Specifyin V.) ❑ Other (Specifyin V.) Z Other (Specifyin V.) ❑ Other (Specifyin V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : 0 Pass ❑ Fail Z Pass El=Fail Pass ❑ Fail Z Pass Z Fail V. COMMENTS Any items marked "Fail" above must be explained in this section. Any additional comments maz also be p1 v�ded Mere.RE, r, APR I14 VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCT `- hereby certify that the spill containers were tested in accordance with California Code of R�91 , 16 ion`s, 'Ti41e 23 , Division 3 , Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate . UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council